CMS Patient Safety Structural Measure
CMS's new IQR Patient Safety Structural Measure requires hospital attestation on staffing, culture, and leadership commitment to safety, starting with 2025 data. Here's what your hospital needs to submit and how to prepare.
From NPSGs to a New Structural Standard
Effective for the CY 2025 reporting period, CMS's Patient Safety Structural Measure requires hospitals participating in the Hospital IQR Program to publicly attest to 25 statements across five domains: leadership commitment, staff empowerment, learning system maturity, transparency, and accountability for patient safety.
What This Means for Your Hospital
Attestation-based measures create real accountability: hospital leaders must sign off on statements about staffing adequacy, safety culture, and whether frontline staff feel empowered to report concerns without fear of retaliation. Data collected during the January-December 2025 measurement period must be submitted between April 1 and May 15, 2026 through NHSN, and results will appear on Medicare.gov starting in late 2026. The CESA Group helps hospital and critical access hospital leaders assess readiness, close documentation gaps, and build the safety culture practices the measure is designed to verify.
Ready to Prepare for the New Measure?
Whether you're screening a new case or preparing for trial, we're available for a confidential initial consultation. Reach out and tell us about the matter, we'll let you know quickly whether we're a fit.